Research Spotlight

Fernandez, H. T., P. T. W. Kim and G. Testa (2016). “Adrenal cortical carcinoma with pulmonary emboli: A unique presentation of a rare tumor with extensive tumor thrombus and inferior vena cava extension.” International Journal of Hepatobiliary and Pancreatic Diseases 6: 30-33.

Full text of this article.

Introduction: Adrenal cortical carcinoma (ACC) is rare, and presenting symptoms vary widely depending on functional or non-functional endocrine status. These tumors are most commonly treated with surgical resection and postoperative mitotane administration. Case Report: This is an unusual presentation of a 23-year-old female with no significant past medical history, admitted to the hospital with syncope and dyspnea. Computed tomography angiography (CTA) demonstrated extensive bilateral pulmonary embolisms, with an associated 16-cm assumed right lobe hepatic mass with suprahepatic vena cava tumor thrombus extension beyond the level of the hepatic veins. The patient underwent a complete resection of the right adrenal mass, with inferior vena cava resection, thrombectomy, and placement of caval interposition graft without the use of bypass. Pathology was consistent with adrenal cortical carcinoma. Conclusion: This case of an adrenal cortical carcinoma, with a rare presentation of bilateral pulmonary embolisms, was treated with a surgical R0 resection. This included a right adrenalectomy with IVC resection and interposition graft. Tumors with IVC involvement and tumor thrombus can be treated with surgical resection and IVC grafting, without the use of bypass.

Joseph, S. M., M. A. Brisco, M. Colvin, K. L. Grady, M. N. Walsh and J. L. Cook (2016). “Women with cardiogenic shock derive greater benefit from early mechanical circulatory support: An update from the cvad registry.” J Interv Cardiol 29(3): 248-256.

Full text of this article.

OBJECTIVES: The aim of this analysis was to assess survival differences between men and women supported with Impella 2.5 (Abiomed Inc., Danvers) in the setting of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). BACKGROUND: Data on sex differences in outcomes of CS with mechanical circulatory support are sparse. METHODS: Patients enrolled in the cVAD Registry who underwent percutaneous coronary intervention (PCI) and Impella 2.5 support for CS complicating an AMI were included. Differences between men and women were examined. RESULTS: In total, 180 patients were analyzed. Women (n = 49, 27.2%) were older (71.0 +/- 12.8 years vs 63.8 +/- 13.0, P = 0.001), smaller (BSA 1.82 +/- 0.22 vs 2.04 +/- 0.24 m(2) , P < 0.001), and had a higher STS mortality risk score than men (27.9 +/- 17.0 vs. 20.8 +/- 16.8 P = 0.01). There was no difference in survival to discharge (P = 0.3). Patients receiving the Impella 2.5 pre-PCI had significantly lower inpatient mortality than those who received support post-PCI (P = 0.003). However, the magnitude of the survival benefit was significantly greater in women who received the Impella pre-PCI as compared to men. Overall, 68.8% of women survived with pre-PCI Impella 2.5 versus 24.2% post-PCI (P = 0.005) whereas 54.2% of men survived with pre-PCI Impella 2.5 versus 40.3% post-PCI (P = 0.1, p-interaction = 0.07). No differences in timing to intervention were found between men and women. CONCLUSIONS: Early initiation of hemodynamic support prior to PCI with Impella 2.5, in the setting of AMI complicated by CS, was associated with a greater survival benefit to hospital discharge in women compared to men, despite a higher predicted risk of mortality and a greater revascularization failure rate for women.

Krekow, L. K., B. A. Hellerstedt, R. P. Collea, S. Papish, S. M. Diggikar, R. Resta, S. J. Vukelja, F. A. Holmes, P. K. Reddy, L. Asmar, Y. Wang, P. S. Fox, S. R. Peck and J. O’Shaughnessy (2016). “Incidence and predictive factors for recovery of ovarian function in amenorrheic women in their 40s treated with letrozole.” J Clin Oncol 34(14): 1594-1600.

Full text of this article.

PURPOSE: This prospective study assessed the impact of 2 years of aromatase inhibitor (AI) therapy on the incidence of ovarian function recovery (OFR) in women age 40 to 49 with estrogen receptor-positive breast cancer who were premenopausal at diagnosis and who underwent chemotherapy-induced amenorrhea during adjuvant treatment. PATIENTS AND METHODS: Women age 40 to 49 with estrogen receptor-positive breast cancer who had ceased menstruating with adjuvant cyclophosphamide-based chemotherapy, had postmenopausal serum estradiol (E2), and had received tamoxifen for >/= 1 year were treated with letrozole (2.5 mg) daily for >/= 2 years. Serum follicle-stimulating hormone (FSH) and E2 were measured at baseline and over 2 years. A general linear model was used to assess serial FSH by OFR. Logistic regression was used to assess baseline predictors and OFR. RESULTS: The study enrolled 177 women (145 women age 45 to 49 years and 32 women age 40 to 44 years). Of 173 evaluable patients, 67 (39%; 95% CI, 31% to 46%) regained ovarian function; 11 of these patients (6%; 95% CI, 3% to 10%) resumed menses, and 56 of these patients (32%; 95% CI, 25% to 39%) developed premenopausal E2 without menses. Among AI-naive patients, serial FSH significantly increased over time (P < .001), did not vary significantly by OFR status (P = .55), but showed mild evidence of a decrease after month 12 for those who resumed menses (P = .0989). Age less than 45 years and inhibin B were significant multivariable baseline predictors of OFR. CONCLUSION: These results emphasize the challenge in determining definitive menopause in women with chemotherapy-induced amenorrhea. The risk of OFR during treatment with AIs in amenorrheic women in their 40s is high, and AI therapy should be avoided in these patients.

Schussler, J. M., S. K. Asrani, M. A. Ramsay and J. F. Trotter (2016). “Use of a pressure wire to evaluate right heart pressures in a pre-liver transplant recipient through a peripheral iv.” Liver Transpl 22(5): 695-697.

Full text of this article.

TO THE EDITOR: The pre–liver transplant cardiovascular evaluation of recipients routinely includes echocardiography to evaluate for the presence of pulmonary hypertension (pHTN), as patients with moderate or severe pHTN have significantly increased perioperative morbidity and mortality. A recent article by Khaderi et al.(1) suggested that portopulmonary hypertension carries even longer-term risks in post–liver transplant patients. It has become standard for patients in whom screening echocardiography suggests systolic pulmonary artery (PA) pressures >45 mm Hg to undergo confirmatory invasive testing with right heart catheterization (RHC). This allows for both confirmation of these findings, as well as initiation of treatment (where appropriate) for pHTN, and subsequent successful transplantation.(2,3) The direct assessment of a patient’s pulmonary pressures requires invasive instrumentation. In a large series of patients with pHTN, the overall risk of complication is approximately 1.1%, mostly due to the access site and bleeding risk.(4) In the general population, the presence of elevated international normalized ratio (INR) or thrombocytopenia increases the risk of invasive cardiac procedures and is a relative contraindication to heart catheterization. In end-stage liver disease patients, there are few data looking at the magnitude of the increased risk. Although there is a general assumption that this risk may be mitigated by administration of blood products (such as fresh frozen plasma or platelets), vitamin K, or recombinant factor VIIa, there are no data to support these maneuvers.(5) RHC has traditionally been performed using catheters up to 8 Fr in size, placed percutaneously through the internal jugular or common femoral vein. Smaller catheters, compatible with sheaths down to 5 Fr in size, make the potential for bleeding less, but there is always the possibility that bleeding complications (sometimes due to inadvertent arterial punctures) can occur when making a venous puncture. We describe the use of a novel pressure wire to easily and safely evaluate a patient’s pulmonary pressures without the need for additional venous punctures or blood products.

Mack, M. and H. Baumgarten (2016). “Just because you get on a scale doesn’t mean you lose weight: Is meetbaar beter really measurably better?” Eur J Cardiothorac Surg 49(6): 1669-1670.

Full text of this article.

The article by van Veghel et al. [1] describes a national initiative in the Netherlands termed ‘Meetbaar Beter’ or in English ‘Measurably Better’. The stated goal of this multicentre effort according to its website ‘aims to improve quality and transparency of care for patients with heart diseases by measuring limited patient-relevant outcome measures’. Those outcomes include survival, degree of health/recovery, time to recovery and return to normal activity, disutility of the care of treatment process, sustainability of health/recovery and nature of recurrences and long-term consequences of the therapy. By doing this, they are proposing to implement a ‘Value Based Healthcare Theory’ by ‘measuring patient relevant outcomes and sharing and adopting each others best practices’.